Disruptions and opportunities in sexual and reproductive health care: How COVID‐19 impacted service provision in three US states

Abstract Context The COVID‐19 pandemic abruptly disrupted the provision of sexual and reproductive health care in the United States. Methods We conducted interviews with family planning clinic staff at 55 health care facilities in Arizona, Iowa, and Wisconsin in late 2020 and early 2021. We asked respondents about the challenges they faced and ways they adapted their service provision as a result of the pandemic. We conducted content and thematic analyses of the interview transcripts using an inductively developed qualitative coding scheme. Results Family planning clinics and providers made a variety of changes to their clinic operations and service delivery. The three major areas of change for these facilities were implementation of COVID‐19 safety procedures, shifting service delivery and staffing to meet patient needs, and the rapid uptake and expansion of telehealth. Conclusion While providers faced many challenges, they also described opportunities to innovate and rethink standard of care protocols that may continue to shape sexual and reproductive health care even after the pandemic abates.


INTRODUCTION
The COVID-19 pandemic disrupted the provision of health care throughout 2020 and 2021 in the United States (US). During the beginning stages of the pandemic, in early to mid-2020, health care providers grappled with myriad impacts on their ability to provide care: resources were diverted to address the crisis, 1 the health care workforce experienced unprecedented stress, 2 patients avoided preventive health care out of fear of exposure to the virus, 3 and health care facilities revamped workflows to provide services. 4 These general disruptions to health care were compounded in several ways for sites providing family planning services,* such as federally qualified health centers (FQHCs), community health centers (CHCs), health departments, and specialized sexual and reproductive health (SRH) clinics. Many of these sites receive federal Title X funds, which support the provision of family planning services to people living on lowincomes, 5 un-and under-insured individuals, and historically oppressed groups like Black and Latinx individuals and people of color.
The pandemic occurred during a time of upheaval due to the Trump administration's 2019 Title X rule, which prohibited clinics from receiving Title X funding for family planning services if they provided abortion referrals. 6 Furthermore, in the initial months of the pandemic, states issued emergency orders regarding essential services and these sites grappled with the burden of SRH services, particularly abortion, being deemed "non-essential" by some states and localities. 7,8 Early in the pandemic, researchers began examining the effects of

Sample and recruitment
We conducted this study in Arizona, Iowa, and Wisconsin as part of the Reproductive Health Impact Study (RHIS), a multiyear (2017-2022) research and policy tracking initiative examining the impact of federal and state policy change on population-, provider-, and individual-level outcomes related to publicly supported † family planning care. The RHIS team selected states for their differing family planning policy contexts to allow for examination of state and federal policy impacts but without regard to the COVID-19 situation in each state (see RHIS website 15 for more information on the overall study). Of the study states, only Wisconsin designated some SRH services essential, 7 although Arizona and Iowa enacted state policies to expand telehealth access while Wisconsin did not. 16 As one component of the RHIS initiative, we conducted in-depth interviews with clinic administrators, family planning managers, or staff members in similar roles at family planning clinics. Although this study was not originally designed to examine the impact of the pandemic, we expanded our research focus and interview guide to explore this issue.
Aligned with the focus of the larger RHIS work, we identified our sample through referral from the states' current and/or former statelevel Title X grantee organizations administering this funding within their networks, snowball sampling from interviewees, and outreach to eligible respondents whose facility participated in other components of the RHIS initiative. Our study team stopped recruiting participants when we reached data saturation, 17,18

demonstrated by respondents reporting information represented in previous interviews. Between
August 2020 and January 2021, we conducted interviews with 57 respondents at 55 family planning health care facilities (at two sites, we spoke with more than one respondent, per respondents' request).

Data collection
Each interviewer (PC, MK, and JM) conducted one pilot interview with a respondent meeting our eligibility criteria in a non-study state (Maine), to avoid piloting with potential respondents. The study team used feedback from the pilot interviewees to improve the flow and clarity of the interview guide before beginning the study.
Within the existing interview guide, focused on understanding the broader impact of policy change on the delivery of publiclysupported family planning care, we developed a section to gauge the effect of the COVID-19 pandemic on this care. At the outset of the interview, we asked respondents to provide background information on their health facility, including the SRH services they provide and changes that occurred at the larger health care network in the 18-24 months before the interview. Next, interviewers asked respondents questions about how their facility had been impacted by the pandemic. Specifically, we asked interviewees about any changes to clinic operations, contraceptive service provision, financial well-being, and how social distancing measures (such as telehealth and curbside service) were or were not implemented as well as the subsequent reactions from providers, staff, and patients. For the purposes of this research, we define telehealth as the provision of health care services by a health care provider via technology, including video calls, phone calls, and app-based services. ‡ Interviewers also asked respondents to speak to the potential permanence of any changes made due to the pandemic.
Three members of the study team (PC, MK, and JM) conducted interviews, which lasted approximately 75 min. We offered Zoom video, Zoom audio, and phone interview options to respondents to minimize disruptions to clinic staff schedules and to maximize the ability to speak with providers across states. We audio recorded interviews and interviewers and participants were in private spaces during the interview. All participants orally consented prior to the interview; participants could stop participating in the interview at any time or decline to answer any interview question. We offered respondents a USD75 gift card as remuneration for participation. The Guttmacher Institute's federally registered institutional review board approved the study.

Data management and analysis
A third-party transcription service transcribed audio recordings of interviews and five research assistants reviewed transcriptions for accuracy and removed identifying information. We used NVivo12 to organize and code deidentified transcripts and generate code reports.
We inductively developed a coding scheme based on the interview guide and existing literature and conducted content and thematic analyses of the respondents' narratives after reading all transcripts.
Initially, we divided eight transcripts among the analysis team (PC, MK, JM, and AV) for independent coding. The team met to resolve differences and strengthen the coding scheme by developing new codes. The analysis team then divided up all transcripts and at least one team member coded each transcript using the refined coding scheme. The analysis team met regularly to review coding progress and resolve analysis questions. Once the coding process was complete, we generated code reports for facilities in each state by clinic type. We divided code reports among team members and reviewed them to explore sub-themes before summarizing findings and subthemes into matrices, organized by state and clinic type. The analysis team conducted multiple rounds of review to identify and consolidate themes. In the following section, we describe how the COVID-19 pandemic affected sites across clinic type and state.

RESULTS
The 57 participants were from 17 sites in Arizona, 20 sites in Iowa, and 18 sites in Wisconsin (see Table 1), a roughly even split by state.
Respondents were typically clinic managers or family planning coordinators, although specific roles and titles vary across sites. Over onethird of respondents worked at specialized SRH clinics, while over one-quarter were employed at a CHC or an FQHC. Just under 25% worked at health department sites and the remaining 14% worked at hospital sites or other clinic types.
As a result of the pandemic, family planning clinics and providers across all states and facility types made a variety of changes to their clinic operations and service delivery. Our findings are organized according to three domains that emerged among our respondents' accounts: (1) implementation of safety procedures in clinics to minimize the risk of exposure to COVID-19; (2) shifting service delivery and staffing to meet pandemic-related patient and provider needs; and (3) experiences with telehealth, including benefits and challenges of telehealth adoption or expansion. We identify the clinic type and state when using direct quotes from respondents and, where relevant, describe differential experiences within these domains.

Implementation of safety procedures
Respondents reported making several changes to decrease their patients' and providers' risk of exposure to COVID-19 while continuing to provide care. Many facilities implemented screening procedures by deploying facility staff to ask patients whether they had any symptoms associated with COVID-19 before entering the facility and taking their temperatures upon arrival. If a patient was found to have COVID-19 symptoms, they were rescheduled to avoid potential exposure and clinic shutdowns.
I think the big thing is really, just, you know, screening people when they make appointments and when they come in, so we know they are safe.
[…] we've had a couple of cases where somebody came into the clinic and we realized that they were a potential exposure, and we had to shut down a room.-Hospital site, Iowa.  Facilities also increased the use of personal protective equipment (PPE) such as requiring, and often providing, masks for patients, staff, and providers as well as requiring gloves, eye protection, and gowns for providers. Some facilities made these changes to prioritize patient safety in the absence of specific government regulations. For example, respondents in Iowa and Wisconsin described implementing masking protocols when their state did not have an applicable mask mandate.
Some facilities experienced shortages of supplies making routine use of PPE a challenge. In some cases, staff re-used items or paused clinic services due to insufficient access to PPE.
Simultaneously, staff increased the frequency and depth of cleanings throughout clinics and between each patient, particularly for "high touch" areas. This often placed an increased burden on staff and contributed to some sites offering fewer appointments. These reductions were often short-term and abated as clinics adjusted to the new protocols.
We've had to greatly, greatly limit our hours and then even on top of the hours, how many patients we can see in a day because we've spaced them so far apart so we never have more than one patient in the waiting room at a time. We have to clean and wipe down the waiting room, the restroom and the exam room in between every single patient. We're really only able to see maybe 7 or 8 patients a day spacing that far apart.
Every single day is booked and even then there's patients that can't get in. So the huge limitation in services is how we're affected.-Health department site,

Arizona.
Many clinics changed their hours or altered their appointment practices to modify, reduce, or eliminate walk-in services and waiting areas to accommodate social distancing and avoid crowds. Respondents described how their clinics' elimination or significant reduction of walk-in appointments and waiting rooms allowed staff to control the number of patients in the space at any given time. In lieu of a waiting room, some patients were asked to wait outside or in their cars until their appointment time.
We have stopped walk-ins. We used to have a lot more walk-ins where people would say, "Do you have time to do a pregnancy test? Can I get in today?" Something like that. We make them do appointments.-Health department site, Iowa.
Similarly, many clinics that previously allowed patient guests for comfort, convenience, or support grappled with whether and when to allow guests in the face of social distancing requirements and fears of viral exposure. Respondents described a range of policies that generally required patients to be unaccompanied unless certain circumstances applied, such as parents/guardians of small children or adolescent patients who wanted a parent/guardian present.
We do prefer that they come by themselves. Sometimes that doesn't happen, especially with single moms with littles at home. They oftentimes will have to bring their children, but that's completely understandable.
We just make accommodations for that.-Health department site, Iowa.
Some clinics also allowed a guest for certain procedures, such as prenatal ultrasounds. In general, however, clinics maintained no-guest policies to limit the number of people entering the clinic.

Shifting service delivery and staffing
Beyond changing clinic operations, clinics altered their service delivery protocols to minimize the risk of COVID-19 and shifted staffing to accommodate evolving patient and provider needs linked to the pandemic. Many clinics saw a decrease of in-person visits as a result of revamped clinic protocols, postponement of non-urgent appointments, and decreased patient demand for in-person care, although several specialized SRH sites reported increased patient volume due to their nearby health care counterparts suspending SRH care to focus on COVID-19 response. Facilities also expanded telehealth offerings and adopted curbside and mailing options for certain contraceptive refills (e.g., pill, patch, ring, emergency contraception) and STI testing and treatment.
Many respondents reported that their clinics canceled or postponed appointments deemed non-urgent, such as elective procedures, "well woman" exams, and pap smears, during the initial months of the Sites also had to contend with shifts in staffing capabilities and needs, as changing workflows affected staffing models, COVID-19 exposure and quarantines led to unpredictability in staff availability, and financial concerns led to staff cuts at some clinics. Cuts in staffing also affected the number of appointments clinics had available for SRH services. Staff burnout was a prevalent concern for most sites but was especially pronounced at health departments and FQHC sites, where staff were often engaged directly in the local COVID-19 response.

DISCUSSION
The first year of the COVID-19 pandemic created many challenges for the provision of SRH care and our respondents described a variety of adaptations their clinics made to keep providing needed care while still protecting patients and staff. Similar to Weigel and colleagues' findings among obstetrician-gynecologists (Ob/Gyns), our respondents reported experiencing major pandemic-related challenges and changing service delivery to meet patient and provider needs as a result, particularly through the rapid expansion of telehealth. 4 We found that changes were made while clinics dealt with concerns about decreased revenue, workflow adaptations to telehealth platforms, shifting patient needs, and staff burnout. While staff morale was a concern for most of our respondents, we found that this concern was more prevalent among respondents from FQHCs and health departments than other site types, mirroring Prasad and colleagues' findings that health care workers' experiences of COVID-19-related stress varied by worker role. 2 Overall, respondents described the ways in which the disruptions of the pandemic and policy changes promoted innovation and rethinking of protocols that may carry through even as the immediate concerns of the pandemic abate. The innovations in access that providers experimented with during the pandemic, such as extending contraceptive refills without in-person appointments, lengthening the time between DMPA shots, and providing presumptive STI treatment should be codified into practice guidelines to ensure patient access is at the forefront. 22,23 Prescription requirements for contraceptive methods that have been widely studied and used should be reassessed to allow for greater access outside of the clinical space and reduce barriers for those who do not have easy access to a physician. 24 Providing over-the-counter access, along with mail and curbside pickup to safe, effective and acceptable contraceptives can reduce inequities in contraceptive access. 24 Furthermore, officially recognizing SRH care as an essential service, as 14 states did in early 2020, may help to ensure that patients can access vital health care and that providers have the resources they need to continue serving patients. 7,22 Although we did not find differential results by state, despite different state responses to the pandemic, this should not be taken as evidence that state policy does not matter, especially given that prior research in these study states found that patients in Arizona were more likely to report difficulties accessing SRH care than those in Iowa and Wisconsin. 25 However, this research project was designed in the context of the overall Reproductive Health Impact Study rather than to shed light on COVID-19 responses and all three of the states enacted some form of pandemic response: Wisconsin included SRH in the definition of essential services 7 and Arizona and Iowa expanded telehealth services. 16 This may explain why state differences were not pronounced in our qualitative findings.
Although we found minor differences in COVID-19 impact among our respondents based on site type, mentioned above, most of our findings were similar across site types, demonstrating that many SRH clinics experienced similar challenges in the early months of the pandemic and implemented similar procedures as a result. We uncovered fewer disruptions to care due to COVID-19 than Roberts and colleagues' study of independent abortion providers, perhaps in large part because contraception was not targeted by politicians seeking to restrict access to the extent that abortion was in the early months of the pandemic. 7 In addition, some specialized SRH clinics and CHCs/ FQHCs in our sample are part of larger networks of clinics, which allows for greater resource sharing, and this may further mitigate the impacts as compared to those of Roberts and colleagues. However, in the wake of the Supreme Court's decision in Dobbs v. Jackson Women's Health Organization, there has been increased concern regarding the ripple effects and potential for subsequent attacks on access to contraception, 26  However, research has found that contraceptive patients rank their experiences with telehealth services as less patient-centered than inperson care, which highlights the need for providers to continue to improve their telehealth services. 27 Several challenges our respondents expressed mirrored those reported elsewhere, such as the limitations of telehealth for provision of certain services and the difficulties experienced by some patients in using telehealth. 4 Our study expands this literature by distinguishing between the telehealth issues that stem from the stressful and rapid conditions under which telehealth was expanded and which have been ameliorated as the pandemic wore on and those that require more innovation and attention to address. These latter challenges, such as ensuring patient access to Wi-Fi for appointments, assisting providers in building rap-

ACKNOWLEDGMENTS
The authors are grateful to the clinic staff who participated in interviews, without whom this study would not have been possible. We gratefully acknowledge the critical feedback and contributions from the following ENDNOTES * Family planning services include, but are not limited to, contraception services, pregnancy testing and counseling, fertility and infertility services, preconception health services and sexually transmitted infection services. For the purposes of this analysis, we do not include abortion care in our definition of family planning services. † A publicly supported clinic is a site that offers contraceptive services to the general public and uses public funds (e.g., federal, state or local funding through programs such as Title X, Medicaid or the FQHC program) to provide free or reduced-fee services to at least some patients. ‡ In our interviews, respondents use the terms telemedicine and telehealth interchangeably.